The North Coast is a leader in concussion research, but can awareness change an old-school sports ethic?

Humboldt State University athletes, including this year’s record-setting football team, are subjects of a growing national concussion research program.

It was Labor Day weekend and Alex Yeoman was skidding across the waters of Trinity Lake on an inner tube.

Alex was a 16-year-old junior at Arcata High School, a three-sport athlete with a soaring grade-point average who never missed school. On that fall afternoon, Alex hit a funny hop, went flying, caromed off his cousin and into the lake. He came up rubbing his head, but seemed fine.

Later that evening, he barbecued with family and friends. The next day he drove home. That evening, in front of the TV, he didn't feel well. The temple he'd knocked against some bony part of his cousin's body the day before had swollen up. He threw up a few times, but thought it was something he'd eaten.

On the first day back at school he was feeling groggy. He chalked that up to food poisoning until one of his teachers came to him and said, "There's something not right with you."

After classes, Alex went to the school's athletic trainer, who almost immediately called his mom. "I'm certain Alex has a concussion," he told her.

OK, his family thought: Concussions take a couple weeks to clear up. He'll take a break from cross-country but he'll be fine by the time basketball season starts. SATs lurked around the corner, but that was hardly a concern. "I never thought that three-and-a-half years later I'd be helping him deal with the life changes it's posed for him," says Alex's mom Lynda on a recent morning.

Alex was one of about 4 percent of concussion sufferers who experiences "post-concussion syndrome." No one really knows what happened to his brain on that September afternoon in 2012. He has visited multiple neurologists. Pediatricians cleared him to go back to sports, but he suffered from debilitating headaches at track and dizzy spells in basketball.

Mental strains, like exams or long study periods, sent him into seizure-like states that his family began to refer to as "zone-outs." He visited a vestibular therapist, who helped him with balance and motor skills. He re-taught himself how to learn. His photographic memory is all but gone.

Alex's junior year was tough — he had to step away from sports and deal with regular zone-outs. Sometimes he couldn't finish the school day and his mom left work to pick him up. But the emotional toll didn't really set in until his senior year. He started to feel better, his spells fewer and farther between. But then they'd come roaring back. He realized he wasn't processing emotion well. His traditional stress outlet — sports — became nearly impossible for him, and with the loss of athletics came the loss of his social circle.

The hardest part, Alex explained on a recent afternoon, was from about four months to 15 months after the injury. "Somewhere around there, a lot of people go through this period of skepticism," he said. There's no cast on a concussion for your friends to sign, and you can't see the effects of it all the time. No one outright accused him of faking it, but he could sense it around him. "You get to these days where you sort of question it yourself," he says. "You really learn who your friends are in these situations."

Lynda said she's finally gotten to the point where she doesn't cry when talking about Alex's injury. "In his senior year, he said, 'If this is how I'm going to be, I don't know if I want to do it any more,'" she recalled.

Alex has gotten much better, but he still suffers from occasional zone-outs. He's maintaining a 3.73 grade average midway through his second year at University of Southern California, and he's able to exercise again. He's finding coping skills, and he's interested in how his experience can help others. But he's still troubled by uncertainties.

"Certainly it's gotten better, but will he ever be the kind of person he was before the head injury?" Lynda asks. "To be honest with you, I would say: probably not. I don't know that the way he learned before will ever be the way that he learns now, completely."

High on the hill at Humboldt State University, up three flights of stairs, smack dab in the center of the university's sprawling sports complex, sits Beth Larson's office.

The coordinator of the North Coast Concussion Program, Larson has decorated her place with a mix of the whimsical and serious — a Bigfoot figurine, a poster of a chimpanzee wearing headphones, printouts of various colorful brain scans and dozens of books about neuroscience. It suits her personality — sincere and determined but with an infectious laugh. Tall and thin, with shoulder length dirty blond hair, Larson looks like an athlete.

As a November dusk sets on the HSU football team's practice, visible out her window overlooking the Redwood Bowl, Larson talks excitedly about the research she began at HSU in 2008 with the help of a national grant to study concussions and depression in high school and college athletes.

She's continued that work. Eventually, with the help of Director Justus Ortega, she developed the North Coast Concussion Program with the goal of furthering "our understanding of the effects of concussion on brain function, motor control and behavior."

Ortega, a biomechanist, has been leading student and postgraduate research about the physiological effects of concussions and aging on motor and balance functions. Larson has been working more on the coordinating side, rallying doctors, students, athletes, coaches, parents and educators in the area to get behind the cause. It hasn't been an easy road, but it's catching on.

If anything's become clear about concussions recently, it's how little we know about them. A concussion occurs from a blow to the head or violent shaking, which twists or bounces the brain in the skull, "stretching and damaging the brain cells and creating chemical changes in the brain," according to the Centers for Disease Control.

"Very simply, a concussion is a traumatic brain injury," Larson says, adding that doctors and scientist are beginning to steer away from inserting the word "mild" before the definition. That's because, while there are a variety of symptoms that indicate a concussion has occurred, there's no way to tell how bad the concussion itself is, how long it will last or what to expect. "Clinically, there's no litmus test," she says.

The most important thing someone with a concussion can do, Larson says, is stop: Stop playing sports, take a cognitive break, let the brain heal. Usually that takes a couple weeks. Sometimes longer.

The impacts that cause concussions disrupt the 100 billion neurons in our brains that use chemicals to send electrical signals to control our bodies. And while physicians often say concussions aren't structural injuries because they don't appear on CT or other scans, Larson points out that we can't see the "microstructure" of the brain — the tiny pathways the neurons create. At least not while we're alive.

"For me to really be able to see your individual neurons, you have to die and then I would have to dissect your brain," Larson says. "So there's some timing there that's not great."

Post-mortem brain exams have been one of the biggest factors in bringing concussions into America's cultural mainstream. In the early 2000s, a forensic pathologist named Bennet Omalu discovered Chronic Traumatic Encephalopathy in the brain of NFL Hall-of-Famer Mike Webster. The degenerative disease is linked to dementia and other brain disorders and, researchers believed, was brought on by decades of blows to the head. Doctors employed by the NFL quickly moved to discredit Omalu's research (which is the subject of the book League of Denial and upcoming Will Smith movie Concussion), but scientists, according to Frontline, have since discovered CTE in the brains of 87 out of the 91 deceased former NFL players who have volunteered their brains for research.

In several high-profile cases, players have committed suicide by shooting themselves in the chest, reportedly hoping to preserve their brains so researchers could study them intact.

What has grown into the biggest concern for long-term brain health, says Mark Fainaru-Wada, who co-authored League of Denial with his brother Steve Fainaru, is not the huge, wince-inducing tackles on football fields, but the repeated sub-concussive blows that many players — especially on the offensive and defensive lines — take on every single play.

Larson also has damning things to say about the NFL's "risk-management" approach to the concussion issue. "The NCAA is doing better," she says, "but still not completely transparent when it comes to concussions."

The NCAA, along with the Department of Defense, recently became a big sponsor of the North Coast Concussion Program, awarding a two-year, $242,000 research grant as part of a $30 million nationwide initiative.

The program's NCAA grant pays for expanded baseline and post-injury measures of concussions in HSU's 420 Division II athletes. If one of them reports a concussion, researchers will monitor him or her for six months, recording neurocognitive, motor control and behavioral data. Forty other schools around the nation will contribute to the data pool, Larson says, using many different tests to attempt to get a grasp on the concussion issue, which goes beyond sports. The injuries affect veterans and accident victims, and they impact the economy, as well as rates of substance abuse, domestic violence and PTSD.

The program's other work, with college club athletes, high school athletes from 11 schools, and the general community, is supported by the university, high schools or on an individual or group basis.

If research on adult concussions is lacking, similar studies on youth are almost nonexistent, Larson says. All of the media attention is on adults, for one thing, because the most notable cases have revolved around sports stars. Also, huge, huge corporations like the NFL have the money to shovel toward adult research, self-serving as it may be. Researchers using NCAA funding will focus on student atheletes because they're a large population that can consent to research on their own, giving the most impactful statistical results. Researching youth means getting release forms from each and every parent — an arduous task.

It's frustrating, Larson says, especially given the indications that early and regular exposure to concussions and sub-concussive impacts leads to degenerative disease.

"We should be most concerned about the kids and it should trickle up," she says, adding that people's brains are still developing into their 20s. "The whole time we're doing all this research on adults, it's leading to this misconception that kids are somehow unaffected."

The concussion program's national collaboration isn't its only function; Larson and Ortega have been tasked with creating a concussion protocol to be applied at the California State University System's 23 campuses. Since state law has required youth athletes suspected of suffering concussions to have a doctor sign off on their return to play, the concussion program has helped local pediatricians better evaluate concussions.

Larson says many of her days consist of half-hour conversations with parents and their kids about injuries. "I'm not a counselor, but it's really become a counseling thing," she says. "The biggest part is getting people to understand why it matters."

Some of the biggest stumbling blocks have tradition-bound, venerated institutions like high school sports, which celebrate on-field resilience. That old sport ethic — "Don't come off the field unless you've got a visible bone sticking out of your leg, and even then ..." — has gotten Larson cussed at and hung up on.

"If you have a parent, who on the side is saying, 'Oh, well I got my bell rung 85 times and I turned out fine,' occasionally I have to say, 'Well sir, fine may be relative. Have you always had this temper?" she recalls with a slight chuckle. "At one time, we thought cigarettes were good for us as well; we wear seatbelts now, even though our grandmothers survived without them."

Perhaps unsurprisingly, the biggest turnaround comes when a kid is injured and parents become involved. That's exactly what happened with Lynda Yeoman, Alex's mom, who is the principal of Sunny Brae Middle School in Arcata.

Alex has learned coping mechanisms over the last several years, identifying what can trigger headaches and zone-outs, and how to best recover when he's afflicted. He's proactive at school, going to his professors at the beginning of semesters and explaining his problem and how it might affect his schoolwork. So far, his professors have been accommodating and responsive, largely, Lynda thinks, because he approaches them before there's an issue. Alex's zone-outs aren't so much the problem anymore, Lynda says. It's the three-to-four-day stimulus-free recovery period he needs: College doesn't exactly stop for three or four days when Alex needs it to. Occasionally, Lynda will help him keep up in the following days by reading to him from his textbook over the phone.

Lynda's personal experience has made Sunny Brae Middle School a concussion-aware campus. Her students call her "the Concussion Nazi" — a title she's not ashamed of — because she's instated a policy that may be the only one of its kind on the North Coast, let alone the state.

If parents notify the school that a child has been diagnosed with a concussion, Lynda confiscates the kid's books and notebooks. She doesn't let the student access online schoolwork — changing passwords if necessary. She sends the student home until he or she is completely asymptomatic. And when the student returns to class, he or she is excused from making up the missed work.

"And that is non-negotiable to me with my staff," Lynda says. "Every time you engage your brain cognitively [after a concussion] it's like running on a sprained ankle. That's the part that researchers are just starting to understand."

Yeoman's policy may seem like an overcorrection, a response to her son's particularly nasty concussion. After all, 95 percent of concussions clear up in a matter of weeks. But Larson says general science indicates people should take a cognitive, physical and emotional rest after a concussion. For some, it might clear up in a day. Others, weeks. But the point is, she says, students should be allowed to take a break and return on a case-by-case basis.

It's particularly hard for driven students, she says, but that's why her policy is particularly necessary. "We can educate parents and we can educate coaches and we can educate students, but if we don't innately and specifically change the structure of school for kids who are recovering from concussions, it doesn't matter how much education we give them; we're not going to change their behavior."

Lynda has been proselytizing this practice at meetings with other local schools, but she doesn't think it's catching on. There's still a distrust, a concern that students would take advantage of the still-ambiguous ailment to get out of schoolwork. Sure, that may happen, Lynda acquiesces, but without an individualized recovery program for students, she says, it's the academically driven kids who are going to suffer. They'll play through the pain, as it were, even though, "In the big picture of middle school and high school, if they miss a unit it's not going to alter their life forever," she says.

While the concept of academic rest may not be catching on, there has been wider acceptance that youth who suffer from concussions need athletic rest. State law now mandates that youth athletes be cleared by a doctor before returning to sports. Still, Larson estimates, 50 percent of concussions go unreported and Alex Yeoman — speaking from experience — says an athlete determined to return to the court or field can deceive a doctor's exam, even if he or she is still suffering.

But sports are also starting to limit kids' exposure to physical contact; there's less hitting time in football practices, kickoff returns have been shortened to reduce high-speed impacts, and students under the age of 12 are discouraged from heading the ball in soccer practices and matches. Gone are the days when a machine launched soccer ball after soccer ball at kids' heads as a rote training, Larson says, though she still gets die-hard parents who say, "'You have a 12 year old and the ball is coming at your head, what other option do you have?' They're so impassioned. Well, um, I mean, you could always duck. ... When the potential is brain damage, there is another option."

One might expect expanding concussion research to worry high school athletic directors and coaches. A Wall Street Journal report showed that the number of kids aged 6 to 18 playing organized football dropped 5.4 percent between 2008 and 2014, and experts have attributed that to increasing awareness of concussions.

Meanwhile, the number of reported concussions has gone up in recent years, potentially another sign of increased awareness; Larson attributes the spike to increased reporting, not increased concussions. The North Coast Concussion Program has seen more than 800 youth and adult concussions since fall of 2009, about 65 percent of which were sports related.

But local coaches and athletic directors have embraced the concussion program, Larson says, even the few holdouts from the bell-ringer school of thought.

Jack Lakin, the Superintendent/Principal of Ferndale Unified School District, has been involved in youth sports for decades. "We've had concerns about the ability to establish a concussion protocol for some time now," he says.

New state laws and national publicity have gathered momentum toward getting schools to ensure reporting and develop concussion response plans. But with that came increasing pressure on coaches to recognize concussions and act accordingly, Lakin says. "We were relieved when we were able to develop a partnership with Humboldt State, which helps educate the coaching community ... and they have that testing capability to determine if someone has a concussion."

Lakin says the partnership puts the North Coast on the forefront of the state when it comes to addressing concussion issues. McKinleyville High School social studies teacher and Athletic Director Dustin Dutra says the school's next step is to better coordinate communication between coaches, nurses and teachers. At this point, he says, it's largely up to parents to explain that absences or declining academics are due to concussion symptoms.

And while Dutra and Lakin say there appears to be slightly declining enrollment in high school football on the North Coast, neither is ready to make a direct connection to increasing concussion concerns.

A couple days before Thanksgiving, Alex Yeoman is on back home on break from school. A tall, muscular 19-year-old, he's got a boyish face under short, unkempt blond hair. A friend asked him to help coach basketball camp at the Arcata Community Center, and he's standing outside the gym cooling off. He's finally been able to exercise again in the last few months without debilitating headaches.

After tinkering with broadcasting classes his first year, Alex changed his degree to cognitive sciences, a more intellectually demanding field. He says he'd love to go around spreading the message about concussions, but he's busy with school. His mom thinks his change of major is an acknowledgment that he wants to turn his experience into something that can help other people, even if concussions are so individualized. In 10 years, he thinks, cognitive science will have advanced to the point where the blanket term "concussion" will be abandoned — or at least modified to reflect the vast array of damage a "mild" traumatic brain injury can produce.

He talks about his injury, but his eyes really light up as he and his mom talk excitedly about USC football — they've got tickets to the upcoming PAC-12 championship game, and they're hoping USC beats rival University of California Los Angeles to make it to the finals.

Larson grew up loving sports, too. She says she used to tell people she wished that she'd been a boy so she could play college football. When she lived in New Orleans, she had Saints season tickets.

"And ..." she pauses, with a sad laugh, "personally, I haven't — and I can't — I haven't been able to watch a football game in years."

She's not asking anyone else give up that pleasure, but it's soured on her. "That is no longer part of the fun in my life," she says. "I started saying to myself, 'As a viewer, what am I saying? I'm saying I want for grown men ... to knowingly cause themselves brain damage so that I can pay money to this multibillion-dollar organization to encourage this type of behavior. It starts to taste bad."

Everyone the Journal spoke with agreed that sports ethics are the fundamental crux of embracing concussion protections and treatment. "For generations, a source of pride was sucking it up and playing through," Lakin says. "Overcoming that type of culture ... changing attitudes about sports is the biggest challenge."

Much emphasis has been put on football, and perhaps rightly so. The sport has surged in popularity nationwide, coinciding with marketing that cranked up the volume on helmet-to-helmet impacts in promo materials. As Fainaru-Wada puts it, "The sport is built on its violence. That's why we all love it."

Dutra says Larson has made herself widely available to parents, coaches and students in the area, which means she's taken most of the heat from parents clinging to old ways. As awareness has grown over the last few years, he's had to deal less and less with people upset about changes to gameplay in response to concussions.

"Nobody's trying to end football," Dutra says. "At the same time, anything to keep people safe and able to enjoy a long healthy life — that's important."

One can argue that adults can do whatever they choose, but that's exactly Larson's point. The long term effects of concussions are just beginning to come to light, meaning generations of competitive athletes never got to make an informed choice.

As a generation of young athletes grows up learning how to tackle properly, or to avoid heading a soccer ball and, instead, develop other skills, gameplay will naturally change. Still, as Dutra says, "Some athletes are stubborn enough that experts need to make that decision for them."

The premise of any sport is to do it faster, stronger and harder than your opponent. Larson's research is about finding ways to avoid concussions and properly treat them. "As a sport lover, I don't want it be in the hands of lawsuits and legislators," she says. "I want people to make good, common sense, proactive decisions to try to protect athletes and sports."

EDITOR'S NOTE:

This story was changed from its original version to correct the spelling of NCCP Director Justus Ortega's name and to properly identify the portions of the NCCP that are funded through an NCAA grant.